Use of Blood Products

Note:

  • This page does not provide official guidelines for use of blood or blood products.
  • It is an aggregation of key peer-reviewed publications.
  • Practitioners are encouraged to provide care as appropriate and feasible during a mass casualty radiation incident and consult experts in managing patients with radiation injury, e.g. Radiation Injury Treatment Network.


Summary of key information


  • High-dose whole body radiation exposure induces hematopoietic cytopenias potentially requiring transfusion of blood products.
  • Cytopenias requiring transfusion occur typically 2 to 4 weeks after high-dose radiation, although time to nadir varies by patient, dose from exposure, and dose rate.
  • Blood loss requiring transfusion may also result from trauma associated with the radiation incident and gastrointestinal losses from a variety of causes.
  • "Cellular" blood products that will be transfused to radiation victims should undergo the following procedures:
  • In the setting of a mass casualty event, if neither irradiation nor leukocyte reduction is available, lifesaving blood products should NOT be withheld.
  • See references below.


top of page


Principles of post-transfusion graft-versus-host disease (PT-GVHD) prevention in radiation event emergencies


  • Avoid unnecessary transfusions.
  • Avoid transfusions from first-degree relatives whenever possible because it increases the risk of PT-GVHD. If no other option is available, this blood must be irradiated.
  • Transfusion of fresh blood, especially that stored for fewer than 3 days, should be avoided whenever possible, except for platelet concentrates.
  • If allogeneic blood transfusion cannot be avoided, prevention of PT-GVHD by irradiation should be considered, especially for fresh blood.
  • If blood transfusion is urgently required, and irradiated blood cannot be obtained immediately, there should be no hesitation about transfusing unirradiated blood or blood components.
  • See references below.

top of page


Kinds of blood and blood components that should be irradiated


  • Whole blood
  • Red blood cells including leuko-reduced red blood cells and frozen red blood cells
  • Platelets
  • Note: See references below.

top of page


Illustration of blood product irradiation


blood product irradiation

top of page


Background information about transfusion issues and policies


  • Post-transfusion graft-versus-host disease (PT-GVHD) can be a life-threatening consequence of transfusing blood into certain patients, including those with significant whole body radiation dose from exposure.
  • If patients receiving large doses of whole body radiation need blood products for any reason, PT-GVHD must be avoided, as treatment is difficult and rarely successful.
  • In PT-GVHD, donor lymphocytes in transfused blood attack recipient organs and tissues. The donor cells recognize recipient HLA, proliferate via lymphoblastic transformation, and are not eliminated by host immune defenses.
  • The fresher the blood, the higher the risk of PT-GVHD, especially with blood used within 3 days after donation.
  • Typical PT-GVHD presents with fever, generalized erythema 1 or 2 weeks after transfusion, followed by liver dysfunction, diarrhea, and bone marrow failure with pancytopenia. Most patients die of multi-organ failure within 1 month of transfusion.
  • PT-GVHD occurs at a higher rate in patients with no history of blood transfusions and in patients who receive blood from relatives.
  • Leukocyte reduction by filtration is not sufficient to prevent PT-GVHD, but it is recommended because it diminishes the following:
    • Febrile non-hemolytic reactions
    • Immunosuppressive effects of blood transfusions
    • Platelet alloimmunization
    • Cytomegalovirus infection
  • Blood and blood product irradiation will prevent PT-GVHD.
  • Both irradiation and leukocyte reduction are recommended when these are available.
  • See references below.

top of page


Recipient risk factors associated with Post-Transfusion Graft versus Host Disease


  • Recipients with pre-existing immunodeficiency
    • Congenital immunodeficiency
    • Hematopoietic stem cell or organ transplantation
    • Fetuses, low-birth-weight babies, and newborns
    • Leukemia and malignant lymphomas
    • Patients undergoing treatment with high doses of anticancer drugs, therapeutic radiation, or immunosuppression
  • Recipients with NO pre-existing immunodeficiency
    • Individuals from an HLA one-way matched donor (recipient lacks HLA antigens on donor cells)
    • Patients undergoing surgery for cardiovascular disease and cancer operations
    • Patients receiving accidental high doses of radiation
    • Patients ≥ 65 years of age

top of page


Patient indications for blood irradiation


  • Cytopenias from whole body radiation exposure
  • Cardiovascular surgery
  • Congenital immunodeficiency
  • Hematopoietic transplantation
  • Fetuses and low birth-weight infants
  • Immunocompromised recipients of organ transplantation
  • Recipient ≥ age 65 years
  • Massive blood loss of severe trauma
  • Malignant lymphomas, leukemias, hematological malignancies
  • Solid tumor undergoing treatment with high-dose chemotherapy or radiation
  • Note: Consult disease-specific guidelines for more individualized recommendations.

top of page


References


General references about transfusion guidelines

  1. Kaufman RM, Djulbegovic B, Gernsheimer T, Kleinman S, Tinmouth AT, Capocelli KE, Cipolle MD, Cohn CS, Fung MK, Grossman BJ, Mintz PD, Sesok-Pizzini DA, Shander A, Stack GE, Webert KE, Weinstein R, Welch BG, Whitman GJ, Wong EC, Tobian AA. Platelet Transfusion: A Clinical Practice Guideline From the AABB. Ann Intern Med. 2014 Nov 11. [PubMed Citation]
  2. Circular of Information for the Use of Human Blood and Blood Components (PDF - 300 KB) (AABB, American Red Cross, America's Blood Centers, Armed Services Blood Program, revised November 2013)
  3. BCSH Blood Transfusion Task Force. Guidelines on gamma irradiation of blood components for the prevention of transfusion-associated graft-versus-host disease. Transfus Med. 1996 Sep;6(3):261-71. [PubMed Citation]
  4. Asai T et al. Guidelines for irradiation of blood and blood components to prevent post-transfusion graft-vs.-host disease in Japan. Transfus Med. 2000 Dec;10(4):315-20. [PubMed Citation]
  5. Kaufman RM, Djulbegovic B, Gernsheimer T, Kleinman S, Tinmouth AT, Capocelli KE, Cipolle MD, Cohn CS, Fung MK, Grossman BJ, Mintz PD, Sesok-Pizzini DA, Shander A, Stack GE, Webert KE, Weinstein R, Welch BG, Whitman GJ, Wong EC, Tobian AA. Platelet Transfusion: A Clinical Practice Guideline From the AABB. Ann Intern Med. 2014 Nov 11. [PubMed Citation]
  6. Schiffer, CA, et al. Platelet transfusion for patients with cancer: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001 Mar 1;19(5):1519-38. [PubMed Citation]

Graft versus host issues and blood irradiation

  1. Del Lama LS, de Goes EG, Petchevist PC, Moretto EL, Borges JC, Covas DT, de Almeida A. Prevention of transfusion-associated graft-versus-host disease by irradiation: technical aspect of a new ferrous sulphate dosimetric system. PLoS One. 2013 Jun 7;8(6):6-9. (Note: This reference is included because it has an excellent literature review of GVH. Readers should not infer an endorsement of a specific irradiator product or technique.) [PubMed Citation]
  2. BCSH Blood Transfusion Task Force. Guidelines on gamma irradiation of blood components for the prevention of transfusion-associated graft-versus-host disease. Transfus Med. 1996 Sep;6(3):261-71. [PubMed Citation]
  3. Theusinger OM, Stein P, Spahn DR. Transfusion strategy in multiple trauma patients. Curr Opin Crit Care. 2014 Dec;20(6):646-55. [PubMed Citation]
  4. Anderson K. Broadening the spectrum of patient groups at risk for transfusion-associated GVHD: implications for universal irradiation of cellular blood components. Transfusion. 2003 Dec;43(12):1652-4. [PubMed Citation]
  5. Webb IJ, Anderson KC. Transfusion-associated graft-verus-host disease. In: Popovsky MA, editor. Transfusion Reactions. Bethesda, MD: AABB Press, 2001: 171-186
  6. Asai T et al. Guidelines for irradiation of blood and blood components to prevent post-transfusion graft-vs.-host disease in Japan. Transfus Med. 2000 Dec;10(4):315-20. [PubMed Citation]
  7. Anderson KC, Goodnough LT, Sayers M, Pisciotto PT, Kurtz SR, Lane TA, Anderson CS, Silberstein LE. Variation in blood component irradiation practice: implications for prevention of transfusion-associated graft-versus-host disease. Blood. 1991 May 15;77(10):2096-102. [PubMed Citation]
  8. Leitman SF, Holland PV. Irradiation of blood products. Indications and guidelines. Transfusion. 1985 Jul-Aug;25(4):293-303. [PubMed Citation]

Platelet transfusion